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Dispute Form

This document is a transaction dispute form from RBL Bank. It requests information such as the customer's name, card number, contact details, and details of the disputed transaction including date, amount, and merchant. The customer must provide a reason for dispute such as lost/stolen card, duplicate charge, cash not received from ATM, etc. and include mandatory supporting documents. The form declares that the information provided is true and warns that the customer is liable for charges if the dispute is found invalid. It requests the customer to sign and send the completed form to the bank within 45 days.

Uploaded by

Vinay Chaudhary
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785 views2 pages

Dispute Form

This document is a transaction dispute form from RBL Bank. It requests information such as the customer's name, card number, contact details, and details of the disputed transaction including date, amount, and merchant. The customer must provide a reason for dispute such as lost/stolen card, duplicate charge, cash not received from ATM, etc. and include mandatory supporting documents. The form declares that the information provided is true and warns that the customer is liable for charges if the dispute is found invalid. It requests the customer to sign and send the completed form to the bank within 45 days.

Uploaded by

Vinay Chaudhary
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Transaction Dispute Form Date:

Name
Card Number
Phone Number (This is important, to allow us
to get in touch with you for further clarification)
Email ID (This is important, to allow us to get in
touch with you for further clarification)

Details of the Disputed Item(s)


Transaction Statement Transaction Disputed
Merchant Name
Date Date Amount Amount

DECLARATION: I am disputing the transaction(s) listed above for the reason as follows:
Reason for Dispute Details Mandatory Document Requirement
Card lost/Stolen on / / / at A.M/P.M
Lost/Stolen Card*** and reported the same to you on / / / at Copy of the FIR filed with Police
A.M/P.M by the way of .
I have been charged twice for the same transaction on Copy of Charge slip showing the actual
Duplicate Charge / / / Disputed Amount . amount

ATM Cash Not A - Cash Not dispensed . Copy of the ATM slip
Received B- Partial amount dispensed by ATM .

 Cash
Paid for Goods by  Cheque /DD/ Credit Card , Cash Memo/Bank Statement/Payment
Other Means Date / / / Counterfoil/Card Statement
Non-Receipt of Goods Tickets/ Merchandise not received, Copy of Letter / Email sent
or Services Expected Delivery Date / / / to Merchant to resolve the issue
Copy of Credit /Refund Slip/
Credit Not Processed Date of Credit Voucher Issuance: / / / Cancellation letter from merchant
establishment
Billed for No-Show Confirmation letter / email
Cancellation Date: / / /
Charge after received from the merchant Copy of
Cancellation Number:
Cancellation Terms & Conditions from merchant
Incorrect Transaction Transaction amount incurred was _, but Copy of Charge slip showing the actual
Amount I have been billed for _. amount
 I have neither incurred nor authorized the above
Unauthorized transactions
Transaction(s)***  I have incurred one transaction-dated at Copy of charge slip for the genuine
the above merchant establishment. However I have not transaction.
incurred or authorized other transactions listed above at
the same merchant.

Primary Cardholder's Signature

1
Dear Customer,

For us to serve you better please provide us with the additional documents as listed above depending on the nature of
the dispute.

We request you to kindly send us the form duly filled and signed at the below mentioned address.

Manager Card Operation


RBL Bank Limited (Formerly: The Ratnakar Bank Ltd.)
Cards Operating Centre (COC)
Unit No 306-311, 3rd Floor, JMD MegaPolis
Sohna Road Sector 48,
Gurgaon-Haryana-122018

As per the Master Card regulation, the letter from the Cardholder is a mandatory requirement and will help us to initiate
a Charge Dispute on your behalf with the concerned acquiring bank. Hence, we would request you to kindly send us the
signed dispute form mentioning the details within 45 days from the transaction date.

Kindly be advised that in case we are not in receipt of the required documents within the specified timelines we would
be unable to raise the dispute with the acquiring bank and the liability of the transaction would lie with you.

You can also scan the request and send it to cardservices@rblbank.com.

DECLARATION

I declare that above given information is true and correct to my knowledge. I understand that I can be held liable for all
charges incurred before the date of reporting of loss/ theft and also, if dispute raised by me is found invalid.

Others (Any additional comments)

*** Allow us to block your card for further investigation (As per MasterCard Norms, Its mandatory)

Primary Cardholder's Signature ______________________

www.rblbank.com

RBL Bank Limited


(Formerly: The Ratnakar Bank Ltd.)
rd
Cards Operating Centre (COC): Unit No 306-311, 3 Floor, JMD MegaPolis, Sohna Road Sector-48, Gurgaon, Haryana-122018 | Tel: +91 124 450 6100
Registered Office
1st Lane, Shahupuri, Kolhapur-416001, Maharashtra, India. | Tel: +91 231 6650214 | Fax: +91 231 2312657386
Corporate Identity No. U65191pn1943PLC007308-E-Mail: customercare@rblbank.com

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